Case Studies: Maternal Rights, Fetal Harms

Abstract

A twenty-two-year-old patient at the county obstetrics clinic received upsetting news when an ultrasound exam revealed that her fetus had hydrocephalus, an abnormal accumulation of cerebrospinal fluid within the ventricles of the brain. The fluid build-up can raise intracranial pressure and enlarge the head, making normal passage of the fetus through the birth canal impossible. If persistently high, the pressure destroys white matter and causes mental retardation. Serial ultrasounds showed progressive build-up of fluid and moderate head enlargement. In addition, a lumbar meningomyelocele was identified, but ultrasound exams revealed no other anomalies. Viral cultures of amniotic fluid and karyotyping revealed no infection or other anomalies. The gestational age of the fetus is thirty-four weeks, and tests show that the fetal lungs are mature. Placement of a ventriculo-amniotic shunt in utero would be possible, but this approach has had limited success. Given mature lungs, the balance of risks and benefits for the fetus favors prompt delivery and postnatal shunting if needed, rather than the still-experimental intrauterine shunting. A decision is needed concerning the method of delivery. Prompt delivery, by cesarean section if needed to avoid trauma to the fetal head, would permit assessment of the infant's condition and provision of treatments, including ventriculo-peritoneal shunt insertion if necessary. Recent reports suggest that among hydrocephalic fetuses for whom full treatment efforts are provided approximately 60 percent survive. Among survivors, about half are mentally retarded in varying degrees. This approach, however, exposes the woman to the various risks associated with surgical delivery, including infection, hemorrhage sufficient to require transfusion, and iatrogenic injury to the urinary tract. An alternative approach would minimize the physical risks to the woman by avoiding cesarean section, permitting the pregnancy to continue until labor begins spontaneously. If the fetal head is too large to pass through the pelvis, a needle can be inserted into the cranium and cerebrospinal fluid extracted to reduce head size. However, this cephalocentesis almost always results in stillbirth or neonatal death within a few days, due to the rapid decompression of the head or needle-induced hemorrhage. What recommendation, if any, should the physician make to the woman? Should he seek a court order for surgical delivery if the woman refuses cesarean section? The questions raised are of great concern to obstetricians detecting prenatal hydrocephalus, a common malformation. Cephalocentesis is ethically problematic for several reasons. First, if one knowingly performs an act that is highly likely to cause the death of another, and if the act causes the death, then it seems reasonable to say that one has killed the other. Even if the purpose is to prevent harm to the woman, and fetal death is not desired, the action would still be killing. Second, because the fetus is near term it deserves serious respect; causing death would then be a grave matter, regardless of whether it is the death of a neonate or of a fetus. Third, it can be argued that physicians have special role-related obligations to avoid causing death. Fourth, it is hardly ever plausible to claim that causing its death is in the interests of the hydrocephalic fetus, and certainly not in the case at hand. Nevertheless, it can be argued that it is ethical for the obstetrician to decompress the fetal head when anomalies incompatible with long-term survival have been detected (such as trisomies 13 or 18), or there are anomalies that are not necessarily incompatible with long-term survival, but are highly likely to result in death or severe handicap (such as holoprosencephaly). In the present case there are no detected anomalies that are certain or highly likely to cause death, and the physician should strive to avoid killing. …